What is the initial treatment for hypoglycemia (low blood sugar) in infants?

Treatment of Hypoglycemia in Infants

For infants with hypoglycemia who are awake and able to swallow, immediately administer oral glucose (preferably 40% dextrose gel) combined with feeding, while infants who are unable to swallow, seizing, or not improving within 10 minutes require emergency activation and intravenous dextrose administration. 1

Initial Assessment and Route Selection

Conscious Infants Who Can Swallow

• Administer oral glucose as the first-line treatment for conscious infants capable of swallowing 1
• Oral glucose (swallowed) is superior to buccal administration and should be the preferred route when the infant cooperates 1
• If the infant is uncooperative with swallowing, sublingual glucose administration using a slurry of granulated sugar and water applied under the tongue is reasonable 1
• Combined oral plus buccal glucose gel (40% dextrose gel) can be used if glucose tablets are not immediately available 1, 2

Specific Glucose Gel Protocol for Neonates

• 40% dextrose gel administered buccally plus feeding (breast milk or formula) is highly effective for neonatal hypoglycemia and supports continued breastfeeding 2, 3
• This approach increases blood glucose by approximately 11.7 mg/dL within 90 minutes, with dextrose gel providing an additional 3.0 mg/dL increase over placebo 2
• Dextrose gel combined with breastfeeding reduces the need for repeat treatment and NICU admissions by up to 73% 2, 3

When to Activate Emergency Services

Immediately activate EMS for any of the following scenarios: 1

• Infant unable to swallow or not awake
• Seizure activity occurs
• Infant does not improve within 10 minutes of oral glucose administration
• Any infant less than 6 months of age with hypoglycemia and altered mental status

Parenteral Treatment for Severe Cases

Indications for IV Dextrose

• Symptomatic hypoglycemia (seizures, coma, severe neurological disturbance) always requires continuous intravenous dextrose infusion 4, 5
• Blood glucose persistently below 1.4 mmol/L (25 mg/dL) mandates parenteral glucose regardless of symptoms 6
• Infants requiring dextrose infusion rates above 12 mg/kg/min need investigation for underlying causes of hypoglycemia 4

Critical Thresholds to Recognize

• Repetitive or prolonged hypoglycemia ≤2.5 mmol/L (45 mg/dL) must be avoided in all infants due to risk of permanent neurological injury 1
• Extremely low glucose (0 to <1.0 mmol/L or <18-20 mg/dL) for more than 1-2 hours with clinical signs indicates high risk for CNS injury 5
• Operational threshold for intervention in at-risk infants is maintaining blood glucose ≥2.6 mmol/L (47 mg/dL) 6

Monitoring and Follow-Up

• Recheck blood glucose 15 minutes after treatment 7
• Expect initial response within 10-20 minutes of oral glucose administration 8, 7
• If hypoglycemia persists after 15 minutes, repeat the glucose dose 7
• Once blood glucose normalizes, provide a feeding to prevent recurrence 9

Critical Pitfalls to Avoid

Never administer oral glucose to infants who are not awake or unable to swallow due to aspiration risk 1

• Do not delay treatment—even brief hypoglycemia can rapidly progress to severe hypoglycemia with seizures 8
• Avoid adding protein or fat to acute treatment, as these do not raise glucose effectively and may delay recovery 7
• Do not use formula alone without glucose supplementation in the acute phase, though formula does provide a greater glucose increase than breast milk alone (additional 3.8 mg/dL) 2
• Blood glucose measurement accuracy is compromised by handheld meters in neonates; blood gas analyzers provide the most accurate results when available 1

Special Considerations for Neonates

• Supervised breastfeeding may be an initial treatment option for asymptomatic hypoglycemia in otherwise healthy term infants 4, 6
• Breastfeeding is associated with reduced need for repeat glucose gel treatment despite not raising glucose as rapidly as formula 2
• Early and exclusive breastfeeding with maintenance of normal body temperature are sufficient preventive measures in healthy term infants 6
• Very few healthy, breastfed term infants have glucose levels <2.0 mmol/L, and values down to 1.7 mmol/L may be acceptable during the first day of life in asymptomatic healthy infants 6

Glucagon Use in Infants

For infants weighing less than 25 kg or younger than 6 years with severe hypoglycemia unresponsive to oral treatment, administer 0.5 mg (0.5 mL) glucagon subcutaneously, intramuscularly, or intravenously 9

• If no response after 15 minutes, an additional 0.5 mg dose may be administered while waiting for emergency assistance 9
• After glucagon administration, provide oral carbohydrates once the infant can swallow to restore liver glycogen 9